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Terminology Services

Information on Standards and Coding for Clinicians

NHS National Services Scotland ISD Scotland & NHS National Services Scotland

Information on Standards and Coding for Clinicians


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Welcome to our clinical coding and terminology web pages for clinicians. Clinical coding plays a vital role in supporting the healthcare decision making process - both at local and at national level. We have put these pages together to help you better understand the role of clinical coding and terminology in supporting healthcare improvement and to demonstrate how you can play a key role in providing Scotland with better quality and accurate information in order to make the right decisions for your patients.

The menu on the left hand side is your link to the various sections but we have also provided a quick description of each section below to let you quickly get to the information you need.

Our Doctors' leaflet Download PDF file [1.5Mb] provides a pocket sized summary guide for medical staff, explaining how data is collected and coded to inform national health statistics, what it is used for, the doctor's role in the process and the type and amount of information necessary to include in a discharge letter to support accurate coding.

Standardising Clinical Information - this section provides an introduction to some of the healthcare information standards used by NHS Scotland for its national data collections and discusses some of the benefits and issues in structuring information for re-use for healthcare decision making. 

Secondary Care Information Collection - this section provides you with more information on how we gather the information for our national statistics from the NHS hospital sites to populate our Scottish Morbidity Records - the source of much of our national reporting and information enquiries. There is also information on our data quality, accuracy and timeliness.

Secondary Care - the clinician’s role - this section provides information on the coding process and illustrates the vital role that the clinician plays in providing enough level of detail to allow accurate coding of an episode of care. Particular attention is given to the role of the discharge summary and a link to an example of a good information summary and how this is then coded is provided. The section also explains how episodes are coded when the information provided is vague or incomplete.

Specialty Information - for some conditions or procedures, national guidance is given to coders to look for out for particular medical terms or phrases. In this section we look at specific conditions and circumstances - such as heart disease, diabetes and mental health and how the detail of your information can help. We also discuss the importance of capturing additional relevant conditions - co-morbidities.

Primary Care and Terminologies - this section looks at other standardised methods of describing clinical care using national and international standardised clinical vocabularies (terminologies) for recording clinical concepts and care with a focus on how they are used in primary care. Differences are explained between classification systems and terminologies. Read and SNOMED CT terminologies are discussed.

How to request your own data from national statistics - there are a number of routes to request your own data from ISD. This section describes some of them.

Getting involved - good quality clinical information is everyone’s concern so get in touch with your ideas and suggestions!

We hope you find the pages useful. If you have any comments or suggestions for additional information or if you would like some bespoke training for your organisation then please contact Janice Watson Terminology Services Manager.

 

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